Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US

Key Points Question Is medical debt in collections associated with population health at the county level in the US? Findings In this cross-sectional study of 2943 US counties, a higher share of the population with medical debt was associated with more days of poor physical and mental health, more years of life lost, and higher mortality rates for all-cause and leading causes of death following a dose-response association. Meaning These findings suggest that medical debt is associated with worse population health and that policies increasing access to affordable health care, such as expanding health insurance coverage, may improve population health.

Models controlled for county-level % of non-Hispanic White, % less than high school graduate, % uninsured, % unemployed, and metropolitan statistical area status, and were weighted by population size, with standard errors clustered at the state level.

eFigure 1 .
Medical Debt by County in the US, 2018 Share of population with any debt in collections.(B) Median debt among people with any medical debt in collections.Data source: Debt in America Project of the Urban Institute.The measure of debt includes student loan debt in default, auto/retail loan delinquency, credit card debt delinquency, and medical debt in collections.

eFigure 2 .
County-Level Debt and Age-Adjusted All-Cause Mortality in the US

89 (0.22, 1.56) 0.009 2.57 (1.63, 3.51) <.001 Data
sources include Debt in America Project of the Urban Institute, American Community Survey, Behavioral Risk Factor Surveillance System, and National Center for Health Statistics (Appendix Table1).Models controlled for county-level % of non-Hispanic White, % less than high school graduate, % uninsured, % unemployed, and metropolitan statistical area status, and were weighted by population size, with standard errors clustered at the state level.Association of Quartiles of County-Level Median Medical Debt With Health Status, Premature Death, and Age-Adjusted Mortality in the US 1 P-values are from T-tests.© 2024 Han X et al.JAMA Network Open.eTable 5.

79 (0.002, 1.58) 0.050 1.21 (0.17, 2.25) 0.023 Septicemia 1.01 (0.58, 1.45) <.001 0.68 (0.13, 1.22) 0.014 0.95 (0.25, 1.64) 0.008
Data sources include Debt in America Project of the Urban Institute, American Community Survey, Behavioral Risk Factor Surveillance System, and National Center for Health Statistics (Appendix Table 1).County-Level Debt by Sociodemographic Characteristics in the US, 2018 Association of County-Level Share of Population With Any Debt With Health Status, Premature Death, and Age-Adjusted Mortality in the US eTable 6.Data sources include Debt in America Project of the Urban Institute and American Community Survey (Appendix Table1).The measure of debt in this Table includes student loan debt in default, auto/retail loan delinquency, credit card debt delinquency, and medical debt in collections.Abbreviations: MSA: metropolitan statistical area; NH: non-Hispanic; API= Asian pacific islander; AIAN=American Indian and Alaska Native; Q: quartile; SD: standard deviation.The range of percentages in each quarter of the counties are presented in 1 st column.eTable 7.

29 (0.27, 0.31) <.001 0.25 (0.22, 0.28) <.001 Nephritis, nephrotic syndrome, and nephrosis
Data sources include Debt in America Project of the Urban Institute, American Community Survey, Behavioral Risk Factor Surveillance System, and National Center for Health Statistics (Appendix Table 1).The measure of debt in this Table includes student loan debt in default, auto/retail loan delinquency, credit card debt delinquency, and medical debt in collections.Number of counties in analysis (N) varies by health outcomes because county level health statistics are not provided if fewer than 10 cases.Association of County-Level Median Debt (in 2018 Hundred Dollars) With Health Status, Premature Death, and Age-Adjusted Mortality in the US eTable 8.

35 (0.25, 0.45) <.001 0.26 (0.16, 0.36) <.001 Homicide and legal intervention
Data sources include Debt in America Project of the Urban Institute, American Community Survey, Behavioral Risk Factor Surveillance System, and National Center for Health Statistics (Appendix Table 1).The measure of debt in this Table includes student loan debt in default, auto/retail loan delinquency, credit card debt delinquency, and medical debt in collections.Number of counties in analysis (N) varies by health outcomes because county level health statistics are not provided if fewer than 10 cases. 1 Crude models were weighted by population size, with standard errors clustered at the state level.Association of Quartiles of County-Level Share of Population With Any Debt With Health Status, Premature Death, and Age-Adjusted Mortality in the US eTable 10.

70 (0.80, 2.61) <.001 3.79 (2.67, 4.91) <.001 Nephritis, nephrotic syndrome, and nephrosis
Data sources include Debt in America Project of the Urban Institute, American Community Survey, Behavioral Risk Factor Surveillance System, and National Center for Health Statistics (Appendix Table